South Africa’s National Health Insurance (NHI) reform was enacted in May 2024. It is the country’s most ambitious effort to achieve universal health coverage (UHC). South Africa has one of the most unequal healthcare systems globally. NHI debates are often framed in technical terms, focusing on cost and feasibility. This analysis shows that power relations and stakeholder interests fundamentally shape the reform’s design. This study draws on policy documents, parliamentary records, and stakeholder submissions from 2011 to 2024, with the political background from 2007 and legal documents to 2026. It applies Walt and Gilson’s policy triangle framework to examine how context, actors, and policy content interact. Key design provisions were embedded in the policy from its inception. These include the continuing voluntary role of medical schemes and accreditation frameworks for private healthcare providers. They reflect the private sector’s structural influence and fiscal constraints rooted in South Africa’s political economy. These are not concessions made during legislative passage. Public-interest civil society organizations were substantively engaged in the NHI process. These include health rights groups, trade unions, and rural health networks. Their influence was limited by restricted access to decision-making forums. The analysis draws lessons for policymakers pursuing UHC reform in contexts where the private health sector is powerful and governance is fragmented. Effective implementation requires governance capacity before or alongside financing. Sustained civil society engagement is an essential mechanism of accountability.

Research on East Asian welfare states has often emphasized regime typologies while paying less attention to the political contestation shaping health policy trajectories. This theoretical/conceptual article develops a historical-institutional framework for understanding Taiwan’s health politics beyond National Health Insurance (NHI). Drawing on official policy documents, legislative materials, ministerial statements, civil society publications, and scholarly literature, the article argues that Taiwan’s health politics is organized by two durable cleavages: the tension between technocratic cost containment and electorally driven expansion, most visible in NHI financing politics, and the tension between public care provision and household-based migrant care labor, most visible in long-term care. Tracing the trajectory from NHI’s establishment in 1995 through LTC 1.0, LTC 2.0, the 2026 launch of LTC 3.0, and the 2024 to 2025 changes to migrant caregiver hiring rules, the article shows that these cleavages tend to generate asymmetric outcomes: incremental expansion, delayed fiscal adjustment, and continued reliance on stratified care labor. By linking long-term care policy to political contestation, labor regulation, and welfare governance, the article contributes to comparative debates on aging, care systems, and welfare state development in East Asia.

Citations

• Health Systems as Contested Ground
  Haejoo Chung, Carles Muntaner
  Health Politics.2026; 1(2): e006.     CrossRef